The Impact of a Rural School-Based Health Center on Students and Their Families in Sneedville, Tennessee: A Case Study.

Transcription

1 East Tennessee State University Digital East Tennessee State University Electronic Theses and Dissertations The Impact of a Rural School-Based Health Center on Students and Their Families in Sneedville, Tennessee: A Case Study. Michael D. Belcher East Tennessee State University Follow this and additional works at: Recommended Citation Belcher, Michael D., "The Impact of a Rural School-Based Health Center on Students and Their Families in Sneedville, Tennessee: A Case Study." (2004). Electronic Theses and Dissertations. Paper This Dissertation - Open Access is brought to you for free and open access by Digital East Tennessee State University. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Digital East Tennessee State University. For more information, please contact dcadmin@etsu.edu.

2 The Impact of a Rural School-Based Health Center on Students and Their Families in Sneedville, Tennessee: A Case Study A dissertation presented to the faculty of the Department of Educational Leadership and Policy Analysis East Tennessee State University In partial fulfillment of the requirements for the degree Doctor of Education by Michael D. Belcher May 2004 Dr. Russell West, Chair Dr. Nancy Dishner Dr. Louise MacKay Dr. Cecil Blankenship Keywords: Rural, School-Based Health Center (SBHC), School Health Services, Health Education, Nutrition Services, Counseling, Psychological, Social Services, Family Nurse Practitioner

3 ABSTRACT The Impact of a Rural School-Based Health Center on Students and Their Families in Sneedville, Tennessee: A Case Study by Michael D. Belcher The purpose of this study was to describe the impact that the school-based health center in Sneedville, Tennessee had on students who attended Hancock County High School. The study documented how the school-based health center affected students, families, and the community of Sneedville. Case study methodology was used to determine if the school-based health center impacted school attendance, mental and emotional health, sexual practices, and overall quality of life for students and their families. Data were collected through 25 interviews with health center stakeholders. The methodology included working with the staff at the school-based health center to identify the key players and key center users over the seven years of the center s existence. An interview protocol was designed for each of the seven groups that were interviewed. Data were collected from current and former students, parents of current and former students, school counselors, teachers, and the school nurse. Students who attended Hancock County High School as well as their parents were impacted by their direct access to primary comprehensive health care services. Benefits to parents included a reduction of time in missed work and lower medical care costs for students without health insurance. The center promoted and improved school attendance while distributing valuable health education information to students and parents. Because the city of Sneedville has only one medical center and no hospital, the school-based health center served the rural residents well. Beginning as one of only three such centers in the United States, the school-based health center endured and evolved into a full-service, comprehensive health care provider. The center is located in an isolated region of Northeast Tennessee; the location added to the center s impact on the residents. This study could provide a model for rural communities seeking ways to serve the health care needs of youth. In this time of economic instability and educational accountability, this schoolbased health center appeared to impact student care, thus allowing students to be more capable and ready to learn. 2

4 Copyright 2004 by Michael D. Belcher All Rights Reserved 3

5 DEDICATION I wish to dedicate this dissertation: To my mother, Ola Jean Belcher, the one person who has always believed in me and provided me with encouragement, support, and resources to promote my education; to my exwife, Kimberly, who was always there to take care of our children in my absence; to my children, Ryan, Jonah, Keesha, and Seth, for their support and understanding; to my staff at Hancock County Elementary School for their support and help with work related situations; to my mentor, Dr. Cecil Blankenship, who believed in me and fostered in me the love of lifelong learning and taught me to believe in myself. And to all the poor country boys who question their abilities and likelihood of accomplishing their dreams. All of you share with me in this accomplishment. 4

6 ACKNOWLEDGMENTS I wish to thank all the people who helped in the preparation of this dissertation. My committee: Dr. Russell West, chairperson, for his time, patience, advice, and understanding; Drs. Nancy Dishner, Russell Mays, Louise MacKay, Ron Lindahl, and Cecil Blankenship for their advice and support. Paulette Reed, office supervisor and head nurse of the Hancock County School-Based Health Center, for giving me her time, interest, and recommendations for this project, for allowing me access to materials and documents, and for providing me with introduction letters and access to participants in this study. Angela Kinsler, my peer debriefer, and Hyle Ferguson, my auditor, for the time and care they took in examining my materials and providing advice. Kathy Wolfe and Sandra Fleenor who helped me with the typing. Peggy Basinger who helped me schedule interviews and individual appointments. Marta Stapleton and Lisa Trent, my office staff, for their constant support and help while I conducted this study and Debby Bryan who edited my work and kept me motivated. 5

7 CONTENTS Page ABSTRACT COPYRIGHT DEDICATION ACKNOWLEDGMENTS Chapter 1. INTRODUCTION TO THE STUDY Statement of the Problem Research Questions Significance of the Study Limitations and Delimitations Assumptions Definitions of Terms Organization of the Study REVIEW OF RELATED LITERATURE Rural Schooling in America Demography and Rural Schools Financial Limitations Facing Rural Schools Challenges Facing Rural Schools Characteristics of Rural Schools Rural Schools in Tennessee

8 Chapter Page Hancock County School System School-Based Health Centers Hancock County School-Based Health Center Health Care and Education General Demographic Information Health and Educational Indicators Availability and Accessibility of Care Qualitative Measures Confidentiality, Consent, and Enrollment Issues Staffing and Budget Development Budget Considerations Problems and the Future Summary RESEARCH DESIGN AND METHODOLOGY Historical Research/Case Study Research Design Participants Permission Procedures Data Collection Records Review Data Analysis Trustworthiness of the Data Summary ANALYSIS OF DATA Benefits of the Rural School-Based Health Center

9 Chapter Page Students Benefits Accessibility Confidentiality Students Spend Less Time Out of Class Treatment for Athletic Injuries Emergency Treatment Transportation for Health Care Counseling Services Health Education Classes Benefits to Parents Cost of Treatment Weaknesses of the Health Center Summary FINDINGS, CONCLUSIONS, AND IMPLICATIONS FOR FUTURE PRACTICE AND FURTHER RESEARCH General Findings Students Benefits Accessibility Confidentiality Emergency Treatment Counseling Services Health Education Classes Benefits to Parents Cost of Treatment Benefits to the Community

10 Chapter Page Weaknesses of the Health Center Conclusions Implications for Future Practice and Further Research REFERENCES APPENDICES APPENDIX A: Teacher Interview Guide APPENDIX B: Parent Interview Guide of Current and Former Students APPENDIX C: Current Student Interview Guide APPENDIX D: Former Student Interview Guide APPENDIX E: Nurse Interview Guide APPENDIX F: Counselor Interview Guide APPENDIX G: Letter of Request to Director of Schools APPENDIX H: Letter of Request to Principal APPENDIX I: Letter of Request to ETSU College of Nursing APPENDIX J: Informed Consent Form (IRB) APPENDIX K: Interview Permission Letter APPENDIX L: Auditor s Letter APPENDIX M: Peer Debriefer s Letter APPENDIX N: Thank You Letter to Participants VITA

11 CHAPTER 1 INTRODUCTION TO THE STUDY Children generally represent pictures of good health. When they do become sick or are injured, most children have access to health care. However, many children in the United States particularly children from rural, poor families are at risk for multiple health problems. For example, poor children may experience two-to-three times the usual incidence for certain preventable medical conditions such as asthma and head-lice (Terwillger, 1994). Rural districts with limited financial resources comprise a large portion of the public elementary and secondary schools in this country. In 1999, one half of the 15,000 regular public school districts in America were considered rural (U. S. Department of Health, Education, and Welfare, 2001). When considering both private and public schools, one fourth of the districts in the nation are rural, and in the mid-western, south central, and western parts of the country, more than one third are rural (U.S. Department of Health, Education and Welfare). Fuguitt and Brown (2000) noted that about 1,100,000 of the nation s 43,200,000 public school students were enrolled in rural school districts. Haller and Monk (2001) stated that 8,000 of America s 84,000 public schools are located in small, rural districts. These small, rural districts serve 2% to 3% of America s public school students, including many who are at high risk for multiple health problems (Stern, 1994). Herzog and Pittman (1995) found that students in rural areas were financially not as well off as their urban peers and were often geographically, economically, and culturally isolated. As noted by DeYoung (1994), parents of children in rural schools often had lower educational levels and held lower educational expectations for their children. Because of the high number of children living in these areas who remain medically untreated, rural health initiatives have developed over the past 20 years. One avenue of service has been the rural school-based health center. School-based health centers emerged in the 1970s and have steadily increased in number to around 1,500 (Hacker & Wessel, 1998). School-based 10

12 health centers are designed to diagnose and treat health problems on the actual campuses of public schools, thus eliminating the problem of accessibility for rural school students. Statement of the Problem The purpose of this study was to describe the development of a rural school-based health center in Sneedville, Tennessee, and to determine the impact of the center on the health and education of the students and their families who live in this rural Appalachian town and attend Hancock County Schools. It is known there are many impediments that interfere with teaching and the achievement of children; however, these problems are more numerous in isolated rural areas. Rural school-based health centers offer hope and promise in combating these issues (Brodeur, Isaacs, & Knickman, 1999). This study investigated the operation of a rural schoolbased health center in Sneedville, Tennessee. Sneedville is located in rural Hancock County in upper Northeast Tennessee. This center is unique in that it serves the children of one of the poorest counties in Tennessee (based on per capita income) and, arguably, in the nation (U.S. Census Bureau, 2001). The geographic landscape is very rugged, large, and isolated with many graveled roads providing transportation routes. Some students ride the bus for over an hour to get to school. The isolation and poverty of the region contributes greatly to the need for accessible, affordable health care for students. Inadequate health care creates many problems that affect the students attendance in school and interfere with academic performance. Gullotta and Noyes (1995) demonstrated that students who had poor health did not perform as well as healthy students and many were considered to be at risk for associated problems. Students who attend schools in this upper Northeast Tennessee region are largely dependent upon their adult caregivers to intervene when health needs arise. Many parents in isolated rural areas do not have the transportation, education, or finances to provide access to appropriate health care. This case study investigated the impact of a rural school-based health center on students health and education in this rural Appalachian County. 11

13 Research Questions The following research questions were formulated to guide the investigation: 1. What impact has the Hancock County school-based health center had on students physical health? 2. What impact has the Hancock County school-based health center had on students mental and emotional health? 3. To what extent has the Hancock County school-based health center had an impact on the health-related behaviors of students? 4. What impact has the Hancock County school-based health center had on educational activities and health related instruction in Hancock County? 5. What impact has the Hancock County school-based health center had on the educational progress of students and the school system s overall educational program? 6. To what extent has the Hancock County school-based health center had an impact on the quality of life for students and their families? 7. What would be the possible impacts of the potential loss of the Hancock County schoolbased health center in the rural community? Significance of the Study Many rural areas in Appalachia are geographically isolated and often economically deprived. This deprivation can interfere with accessibility and convenience of primary health care for the students who live there (Young, DiAngelo, & Davis, 2001). Parents often do not have the resources to provide these necessary health services. Thus, children who live in the areas often do not receive proper preventive health care. Rural schools face many obstacles that limit their abilities to produce graduating students who possess academic abilities comparable to those students from wealthy urban schools (Dryfoos, 1998). Poor health contributes to problems such as absenteeism, lack of motivation to work, clarity of focus, and other obstacles to learning. The information obtained in this case 12

14 study might be helpful in developing a better understanding of the impact a rural school-based health center had on a rural community and, furthermore, the perceptions that developed in the process. Other rural locations in Appalachia with similar geographic areas and occupants might use the information to plan services in their areas. This study evolved because of the lack of research data available on rural school-based health centers; most of the research to date has focused on urban school-based health centers. Thus, a need existed for a better understanding of rural centers and their problems. This case study was significant because it documented the history of a rural school-based health center by examining the premise that rural school-based health centers provide preventive, accessible health care for students in deprived rural counties. Furthermore, this study was significant because it investigated the relationship between the work at the center and the good health practices of the students. Also important was the accessibility these centers provided to rural students who otherwise might not have had opportunities to obtain appropriate health care. Limitations and Delimitations This study was limited to individuals who had a connection to a specific rural schoolbased health center located in upper Northeast Tennessee. The findings from the study can only be related to areas with similar features and characteristics. At the time of the study, the Hancock County school-based health center served students 11 to 18 years of age, in grades 6 through 12. The medical and social characteristics normally associated with pre- and adolescentage students should be understood and expected. The researcher interviewed only those individuals who had a connection with the school-based health center. Twenty-five participants were interviewed comprising operators, caregivers, users, and those associated with the formation, design, and operation of the Hancock County school-based health center. In this study, the researcher attempted to describe the impact the center had on the community during its seven years of operation. 13

15 Assumptions There is an assumption that some personal, preconceived notions and beliefs of the researcher might bias this study. I have worked in a rural school system as a teacher, coach, and principal for 15 years. I have witnessed the benefits and disadvantages of rural schools. I have also been the principal at a school before and after the emergence of a school-based health center and have seen the changes and benefits. The study was based upon participants answers to open-ended interview questions through oral responses and it was assumed that, in general, the participants were thoughtful, forthright, and honest in providing accurate data. Definitions of Terms For the purposes of this study the following definitions were applied: 1. Rural--A rural area is characterized by having fewer than 2,500 people and is said to be nonurban (Rural School and Community Trust, 2002). 2. School-Based Health Center (SBHC)--This is a facility or health center located in a school building or on a school campus that provides on-site, comprehensive, preventive, and primary health care service to include first aid, head lice screening, and other related services (National Association of Community Health Centers, 1994). 3. Health education--this is defined as a planned, sequential, K-12 program that addresses physical fitness and includes activities that students can practice throughout their lifetimes (National Association of Community Health Centers). 4. Nutrition services--this is defined as a planned and nutritional diet program that promotes healthier food choices and support for nutrition instruction (U. S. Department of Agriculture, 2001). 5. Counseling, psychological, and social services--this refers to working with individuals, groups, and systems using both school-based interventions and referrals to community providers (National Association of School-Based Health Centers, 2000). 14

16 6. Family Nurse Practitioner (FNP)--This refers to a resident health professional who is a trained medical scholar and has a depth of knowledge that aids and facilitates the practice of medicine. He or she is not a fully licensed medical doctor and must practice under the supervision of a licensed physician (American Medical Association, 2004). 7. Case study research--this is defined as the explanation of a bounded system or a case (or multiple cases) overtime through detailed, indepth data collection involving multiple sources of information, rich in content. This system is bounded by time and place and is the case under investigation. A case may be a program, an event, an activity, or an individual (Merriam, 2001). Organization of the Study Chapter 1 included an introduction, statement of the problem, research questions, significance of the study, limitations and delimitations, assumptions, and definitions of terms. Chapter 2 includes a review of literature pertaining to rural schools and school-based health centers. The literature review addresses several major areas of focus: (a) rural schools in America, (b) rural schools in Tennessee, (c) rural schools in Hancock County, (d) school-based health centers, (e) the Hancock County school-based health center, and (f) problems and the future. Chapter 3 consists of the methodology and procedures for this study, the research design, the participants, the procedures used, the data collection, the data analysis, and information about steps taken to ensure the validity and reliability of the study. Results of the analysis of the data are presented in Chapter 4. Chapter 5 contains the findings, conclusions, and implications for future practice and further research. 15

17 CHAPTER 2 REVIEW OF RELATED LITERATURE Rural Schooling in America Demography and Rural Schools During most of the 20th Century, powerful economic and social changes took place in rural America. As the economy changed, agriculture was no longer a major source of employment and income. As a result, rural areas experienced an out-migration and the number of students attending rural schools decreased (DeYoung, 1994). Small, rural districts continue to decline in enrollment. Between and the number of regular public school districts in the nation decreased by 700, and 415 of these were in small, rural districts (Haller & Monk, 2001). According to the National Center for Education Statistics (2001), in about 8,000 of the 84,000 public schools in the United States were located in small, rural districts. In spite of the declining numbers, these small, rural districts continue to constitute a large portion of the public elementary and secondary sector of education. According to the U. S. Department of Education (2000), in 1999 half of the 15,000 regular public school districts in America were rural. The majority of these schools were very small, averaging fewer than 100 students per high school grade and 25 students per elementary grade. One fourth of the districts in the nation were small and rural, and in the mid west, south central, and west, the proportion was more than one third (U. S. Department of Education). Previous researchers (Herzog & Pittman, 1995; Phelps & Prock, 1991; Stern, 1994) demonstrated that students in rural areas were not as well off financially as their urban counterparts and were geographically, economically, and culturally isolated. Also, their parents often had lower educational levels and lower educational expectations for their children. While most of the population of the United States lives in urban settings, millions of 16

18 citizens live in vast rural areas (U. S. Census Bureau, 2001). This diversity has important implications for public schooling. School districts must serve a sufficiently large population in order to generate revenue to purchase materials and resources, hire teachers, and build and maintain facilities. However, when the population is widely dispersed, districts often face problems with keeping the community involved, transporting students great distances, and maintaining small economically efficient schools (Fuguitt & Brown, 2000). Financial Limitations Facing Rural Schools Rural school districts typically serve poorer populations with greater needs. Because these rural communities generally have lower property values, the tax base is commonly smaller; therefore, less revenue exists for educational funding (Rural School and Community Trust, 2000). As a result, these small, rural districts have been continually encouraged to consolidate as a response to the funding limitations and inadequate educational services (Bass, 1990). Throughout the 21 st Century, school and district consolidations have often been the only option available when trying to achieve cost savings and improve education in rural districts (Stephens, 1998). Rural communities rely on their schools to serve many functions beyond the primary mission of educating children. Rural school systems provide employment for adult community members and are crucial in the social, cultural, and recreational activities found in communities. Challenges Facing Rural Schools Schools in rural areas and small towns face many challenges in serving the needs of children and in providing for their education. Historically, rural schools have developed several unique methods for educating and serving youth (DeYoung, 1991). Several of these successful educational reform strategies are in widespread use today. According to the National Education Association (2001), such innovative strategies as peer assistance and tutoring, mentoring, multigrade classrooms, multiage classrooms, block scheduling, site-based management, and 17

19 cooperative learning were developed in rural schools. This success in rural education is associated with what makes rural and small town America unique. The smallness or small enrollment of these areas contributed to the close relationships found in many schools among educators, students, parents, and the community at large (Lee & McIntire, 1999). Characteristics of Rural Schools According to data generated by the National Education Association (1998), there were common characteristics found in most rural schools in America. A rural area was defined as having fewer than 2,500 people, and the geographic landscape was defined as rural. There are approximately 84,000 public schools nation wide and 49% of these are located in rural areas. There are approximately 43 million students in schools nation wide and 38% live in rural areas. There are 39,644 public schools operating in these rural areas with the majority (67%) being elementary schools. Rural schools normally have a lower student-teacher ratio than urban schools and often offer more remedial programs for learning-disabled students. However, there were some negatives to these rural schools, such as their probability to not offer preschool or prekindergarten programs and a variety of enrichment activities. Also, rural schools offered fewer job-placement services and had limited curriculums (Rural School and Community Trust, 2002). These schools were more likely to be Title I or Chapter I schools indicating low socioeconomic status (Rural School and Community Trust). Lee and McIntire, (1999) reported that of the nation s 2.56 million public school teachers, 41% taught in rural areas, and schools in these areas, unlike urban schools, were more likely to have a male principal. Haller and Monk (2001) stated that rural schoolteachers spent much less time on extracurricular activities than did urban schoolteachers. Haller and Monk also noted that rural teachers were paid less and had fewer benefits such as paid health and dental insurance. According to Butin (2000), 3 out of 10 rural schools had inadequate buildings and less internet accessibility and rural students traveled much further to get to their school buildings than urban 18

20 students did. While almost half (40%) of the nation s public schools were located in rural areas, only 22% of the total budget went to rural schools, causing some of the aforementioned facility problems (Butin). Rural Schools in Tennessee Tennessee is one of the most populated rural states in the nation, with 1.9 million people living in rural areas (Rural School and Community Trust, 2002). Almost one fourth (24%) of Tennessee s rural students live in poverty and nearly one half (49.2%) do not finish high school (U. S. Department of Health, Education, and Welfare, 2001). The population of the state is 5,689,283. Out of this number, 1,907,239 persons, or 39.1% of the population, were considered to live in rural areas (Haas, 2001). According to the Rural School and Community Trust (2000), 23% of the schools in Tennessee were classified as rural, while 18.8 % of all Tennessee public school students attended rural schools. Over 22 % of the students living in rural areas are considered to be living in poverty, while 8.1 % of the students attend small rural schools (America s Children Report, 2002). The Tennessee educational system consists of 1,646 schools, with 900,510 students enrolled in grades kindergarten through 12 (Tennessee Department of Education, 2002). Many of these students live at or below poverty level; 395,149 or 43.9% receive free or reduced priced meals, and 145,083 or 16.1% are enrolled in special education programs (U. S. Department of Health, Education, and Welfare, 2001). These distinguishing factors designate rural education as an integral part of Tennessee s system of public education. Hancock County School System Hancock County is in a large, beautiful, isolated 222 square mile region hidden deep in the Appalachian Mountains in upper East Tennessee. The population, according to the U. S. Census Bureau (2001), is 6,768; of this number, only 1,257 people live within the city limits, leaving the majority living in the remote rural areas of the county. 19

21 The Hancock County school system evolved from the consolidation of several small, rural community schools to two new facilities that serve all the students. According to G. Seal, Hancock County Attendance Supervisor, school enrollment in Hancock County of students three years and older is 1,406 (personal communication, February 6, 2003). There are 74 kindergarten students, and 702 students in grades one through eight. The high school, grades 9 through 12, has 447 students. The U. S. Census Bureau (2001) reported that of the educational attainment of the population of 25 years old and over (4,617) approximately 1,220 persons or 26.4% had less than a ninth-grade education. In addition, 814 or 17.4% of the population completed grades 9 through 12, but received no diploma. The U. S. Census Bureau reported that 1,477 people or 32% graduated from high school or obtained their General Education Diploma (GED). Considering the county s population 25 years and older, only 513 or 11.1% had some college experience, but did not receive a degree. Furthermore, 124 people or 2.7% had associate degrees, 240 people or 5.2% had bachelor degrees, and 229 people or 5% held graduate degrees. Currently, two comprehensive schools have evolved (via the Basic Education Program) to serve the students in grades kindergarten through 12. The total population in K-12 is 1,104 students; of this number, 99.3 % were White, 188 or 17.1 % received special education services, and 849 or 85.6% received free or reduced-price meals. Both schools have met the state department of education s academic standards of school approval and are in good standing (Tennessee Department of Education, 2002). School-Based Health Centers The earliest school health programs were developed in the late 1800s in response to infectious disease problems (such as smallpox and diphtheria) of immigrant families with a large emphasis on screening in schools and on first aid (Making the Grade, 2001). Although initially supported, attempts to expand school health care increasingly came under attack by organized medicine as being more like socialized medicine. After the 1940s, according to Hurwitz (2000), there were clear distinctions made between medical practice (diagnosis and treatment of disease) 20

22 and school health services (screening, health education, and school environmental health). The predominate model of school health services, especially in rural areas, began to shift toward traditional school nursing roles (Health Care in Schools, 2001). In the 1940s, nurses were better able to provide routine inspection for conditions like head lice, and ensure efficient recommended follow-up care. In the post World War II era, school-children s health again became an increasing focal point because of the high rejection rate among draftees and preventability of their diagnoses. Whereas some cities and school districts responded to these issues with large investments of physicians and nurses time, the majority of schools in the United States had neither medical nor nursing services (Lear, Montgomery, & Schlitt, 1996). This remained true even with the development of many Great Society programs of the 1960s. The majority of the school nursing programs remained a combination of triage, public health assurance, monitoring and detection, and follow-up of acute and chronic health problems (Hacker & Wessel, 1998). Schools provide the logical environment for sustained contact with children. Most schools are located strategically within geographical areas, allowing for easy access and use by communities for various purposes. Schools are often the central location that most community members use for social, recreational, and cultural activities (Stephens, 1998). It is because of this awareness that school-based health centers have evolved. School-based health centers are comprehensive health centers that are located in or near a school. Because schools are centrally located within communities and supply contained accessibility to students, it is only logical that services be rendered there (Brink & Nader, 1984). The first school-based health centers were set up in the early 1970s to ensure that all school-aged children, regardless of socioeconomic status, received quality healthcare (Friedrich, 1999). Although the number of school-based centers grew slowly at first, they grew in popularity after news of their effectiveness spread. The 1980s showed a significant growth of centers, and by the mid 1980s, health centers were present in 41 states and in the District of Columbia (Brindis & Sanghvi, 1997). However, it must be remembered that these clinics served relatively few of the 21

23 more than 16,000 U.S. school districts. Over the past 10 years, there has been tremendous growth in the number of school-based health centers in the United States. A 1998 survey revealed 1,157 centers in 45 states and the District of Columbia that served an estimated 1.1 million students (Center for Health and Health Care in Schools, 2000). Although most centers are located in high schools, an increasing number of school-based health centers operate in elementary schools. According to Rosenbaum (1998), while the role and mission of school-based health centers continued to evolve, there was no standard definition of school-based health centers or a federal agency solely responsible for their standards of operation. Although definitions of school-based health centers vary across the states, the National Association of Community Health Centers (NACHC) (1994), an organization that represents school-based health centers and community health centers in the United States, provided a general description. NACHC defined school-based health centers as: Entities that are: 1) authorized under state or local law to deliver medical and health services to children in schools or educational settings; and 2) organized, sponsored, or supported by school districts, school cooperatives or another educational institution or entity. A SBHC can be organized as an independent, non-profit program or agency, a satellite or a larger clinical provider, or an operational component of a local school system. (p. 6) There are three basic types of service delivery for school-based health centers: the medical type where the centers are the basic providers of primary health and preventive care, the public health type where the school-based health center is responsible for identifying and treating major health problems within the school, and the add-on program type where the school-based health center may duplicate another service available in the community (Making the Grade, 1998). School-based health centers assist students with their physical, social, and behavioral needs by providing primary care within a school-based program (Making the Grade, 1998). According to the Joint Committee on Health Education Terminology (Adams & Johnson, 2000), a comprehensive school health program includes a set of organized policies, procedures, and 22

24 activities designed to protect and promote the health and well-being of students. The centers are specifically designed to address barriers to care such as transportation, accessibility, and personal obstacles. These centers can reach a large number of high-risk populations because they are centrally located in low-income, underserved communities (Adams & Johnson). School-based health centers serve all students, regardless of the students ability to pay. A large portion of the centers users are uninsured or on Medicaid (Department of Health and Human Services, 1993). According to the school-based adolescent health care program (Department of Health and Human Services), almost 50% of the service population is uninsured; Medicaid insures 35% and 16% have private insurance. The school-based health center s population has many needs including confidentially, convenience, age appropriateness, and accessibility. Because of their locations, most centers are in schools with low income and highrisk student populations that are more likely to not seek medical care until problems become severe (Department of Health and Human Services). These centers present a point of access for students who may not feel comfortable seeking any other source of care, especially for mental health and sexual issues. According to the National Clearinghouse for Educational Facilities (as cited in Butin, 2000), there were over 1,500 school-based health centers providing services in areas with a high need for comprehensive and accessible health care. School-based health clinics offer youths and their families a combination of physical and mental health services that are more affordable, accessible, and confidential, thus, leading to their current popularity in the health world (Making the Grade, 1998). Hancock County School-Based Health Center Hancock County is an extremely rural county with a population of approximately 6,700 residents. As the poorest county in Tennessee and one of the poorest counties in the nation, it has an average of $10,823 yearly per capita income (Bureau of the Census Report, 2000). In addition to prior mentioned statistics, 39% of the population lives below the poverty level (U. S. 23

25 D. A. Rural Development, 2000). Because of the excessive isolation and limited resources of this county, the children do not have the exposure or advantages that children in more affluent counties enjoy. In regard to these conditions and the health risks associated with low-income rural areas, the need for health care intervention is paramount. These factors of poverty and high-risk health issues were documented in a proposal grant submitted by Dr. Sonda Oppewal at East Tennessee State University in Seeing the drastic need for affordable, accessible health care, Dr. Oppewal submitted a grant to the U.S. Public Health Service through the division of the Bureau of Primary Health Care and Maternal Child Health. This project addressed the legislative goal of the Health Resources and Services Administration s Healthy Schools, Healthy Communities school initiative for homeless and at risk children and youth (East Tennessee State University, 1995). Dr. Oppewal, who at the time was an assistant professor in the family/community-nursing department, applied for the grant recognizing that Hancock County with only one full-time physician was in dire need of additional health care services. Dr. Oppewal used data from a 1992 survey conducted by the Centers for Disease Control that investigated youth risk behaviors. The study compared risk factors such as unintentional accidents, sexual activity, tobacco use, and wellness of Hancock County High School students with state and national data. The results were alarming and revealed that Hancock County students were at high risk for several health problems, especially tobacco use and absenteeism (East Tennessee State University, 1995). The grant was awarded to Dr. Oppewal in 1994 for $259,192. The one-year federal grant was awarded to establish a school-based health care center on the Hancock County High School campus. The center opened in October The services included: assessment, diagnosis, and treatment of acute and chronic illnesses such as upper respiratory infections, asthma, diabetes, strep infections, and injuries. The grant also supported a health educator who coordinated a risk reduction program that addressed the students needs and improved the risk behaviors identified as high priority from the survey. The purpose was to keep adolescents healthy so they could be better able to learn (East Tennessee State University, 1995). 24

26 The clinic also offered a self-actualization program to enhance the objectives related to risk reduction. A full-time mental health counselor offered programs to promote self-esteem, coping and conflict resolution, problem solving, and assertiveness skills. Students were referred to the mental health counselor for testing, individual and group health counseling, and substance abuse treatment when needed. The center also had a school health advisory board consisting of parents, administrators, and community members to make suggestions and serve the center. The clinic operated from1995 through 2000 under these procedures and guidelines. Funding was funneled through East Tennessee State University as the grantee (East Tennessee State University, 1995). At the initial time of opening, it was only one of three high school clinics in operation; the other two were in Minnesota and West Virginia. In September 2000, the funding was not approved through the Healthy Schools, Healthy Communities initiative. The clinic had no funding until a new source of money was found through another federal grant from the Rural Health Outreach Association. This time the grantee was the Hancock County Public Schools. This funding was for three years, and was slated to end in August It must be remembered that the purpose of the center from the beginning in 1995 was to keep adolescents healthy so they would be better able to attend school and learn. Health Care and Education Good health is essential to children s ability to learn; both physical and mental health issues affect the ability (Carnegie Council on Adolescent Development, 1989). Any health problems such as poor vision or hearing, head-lice, dental cavities, or hunger can interfere with a child s attention and concentration at school (Center on Hunger, Poverty, and Nutrition Policy, 1994). Available and accessible health care in rural areas minimizes the emotional and physical health problems children face and provides better opportunity for success. Physical and mental health problems encourage children to be distracted, miss school, and can take away their zest and motivation to learn. Lack of essential and consistent medical care can also lead to other more critical behavior issues such as attention deficit disorders and emotional traumas. Students 25

27 who have problems with health issues are often unable to follow instructions and remain on task or display inappropriate behaviors, which interferes with their comprehension (Greene, 1998). These acts of misbehavior often require disciplinary action and take away valuable instructional time. The smallest health problems have been shown to interfere with learning and negatively affect students focus and motivation to learn. Even the common cold has been documented to show negative impact on academic performance (Carnegie Council on Adolescent Development). Children need to acquire skills that will promote strong self-esteem, higher-level thinking, and a sense of belonging at an early age. Schools provide children with the environment and foundation for developing these necessary skills that are crucial for proper growth and development (Brown, Grubb, Wicker, & O Tuel, 1985). Overall, health affects education; good health and education are connected, and, generally, children who perform well academically are basically healthy (Robert Wood Johnson Foundation, 1993). Health providers and educators agree that learning comes easier for the healthier child and that frequent problems with vision or hearing impede academic success. According to the Children s Defense Fund (1994), a relationship existed between health and school problems. In a study conducted in 1994, 46 students were examined by the school nurse; their height, weight, eyes, ears, teeth, health history, and birth weight were noted and examined. The researchers concluded that achievement was connected to good health. The study showed that children from low-income families and single parent homes were especially vulnerable or at high risk for health complications and poor school performance (Children s Defense Fund). Schools must develop ways of identifying these potential high-risk students and create ways for diagnosing and treating these health issues before children suffer academically. Attention must be given to the relationship between health and learning and efforts must be made to improve the health of these students. Healthy students learn more effectively and perform better academically than students with poor health. Most health care providers, physicians, and educational professionals agree 26

28 with this thinking and support programs that sustain this idea (Brink & Nader, 1984). It is because of this connection between learning and health, that school-based interventions have increasingly emerged to combat the high-risk categories that many of the poor, rural students fall into throughout this country. School-based health centers can be a vital part of a community s health system, serving traditionally hard to reach populations with a variety of health and support services. The major component of these centers is the access they provide, typically in low income, poverty stricken communities (U. S. General Accounting Office, 1994). Given the role school-based health centers play in the health care network of their communities, they are in a strong position to extend their services to at-risk and underserved youths in the school setting. Building community support for a school-based health center is crucial and is an ongoing process throughout the development and implementation of centers (Elders, 1993). Ideally, the initial idea for a school-based health center will come from the community or school itself and the center can build support around the identification of the needs of the students in the community. The formation of an inclusive early planning group is the first step in generating support for the center. This group is usually comprised of local, concerned individuals who are active political, school, business, or health community leaders. This planning group typically develops and conducts a community needs assessment to determine and validate the health needs of the students in the community (Wolk & Kaplan, 1993). The assessment procedure should involve all county agencies that provide children s services, especially in the health spectrum. Timelines for developing school-based health centers vary widely; the planning process and site development could last from one to three years, depending on the complication of the issues involved such as funding and the school community status (Gadomski, McLaud, Lewis, & Kjolhede, 1998). If the health center evokes or creates any controversy, the planning process could take much longer. A strong planning-advisory board that can effectively deal with controversy is one of the most efficient vehicles in completing the process in a timely manner. 27

29 Shearer (1997) reported that it was extremely important that the needs assessment answer critical questions that could help determine appropriate services. The geographic area is important to know because of transportation demands and travel time. Certainly, the age level of the students to be served is important and should be determined. Also, the positive and negative health indicators should be known and a planned agenda created to deal with them. It is also important to know what other health services are available and what resources already exist that could be shifted to the school-based health center s scope of responsibility. Dryfoos (1998) stated it was essential that input be taken on the health needs of the students, views of the key stakeholders, potential consumers, and other health care providers in the community. Brellochs and Fothergill (1995) suggested that the school-based health centers advisory board should include key community personnel. These members are vital to the planning process and should be carefully chosen. Possible members include board members and staff from the school-based health center. The school principal definitely should be involved, along with the school nurse and counselor. In addition, teacher and student representatives normally are members. Parent representatives (possibly from the P.T.O.) often serve as well as school board members and the system s building representative. In addition, Brellochs and Fothergill suggested that health care and service providers, local health department representatives, and business community leaders were good sources to include. In conducting the initial needs assessment, the advisory board should ensure that an accurate depiction of the community is revealed by reaching out to all community agencies that serve children (Rienzo & Button, 1993). This information gathering comes from various sources through interviews, surveys, action research, or previous demographic statistics. This planning group is also a good source of individuals for a clinic advisory board later when the center is in operation. The advisory board normally assists staff by reviewing tools and questionnaires, suggesting programming, helping write funding proposals, or by generating support for the school-based health center in the community (Brellochs & Fothergill, 1995). 28